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2 Giving Hope WHEN NO ONE ELSE WOULD HELP When a routine examination uncovered a complex aortic aneurysm located precariously close to his kidneys, Michel Alexandre turned to The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center. Herbert Dardik, MD In October 2013, Michel a 74-year-old retired plumber learned about his abdominal aortic aneurysm, a weakening of the lining of the primary artery that delivers blood to the lower half of his body. Michel was not experiencing any symptoms from the aneurysm, but the damaged aorta was ballooning and could have burst or caused his aorta to tear if not treated. Either event could have cost Michel his life. A COMPLICATION Tests revealed that Michel s aneurysm was located above his kidneys. This meant that any surgery to correct the problem would affect the arteries that carry blood to his kidneys. Because of his firmly held beliefs, Michel was adamant that his corrective surgery be performed without the use of blood something his doctors in Florida were unable and unwilling to do because of the aortic aneurysm s location. All the specialists I saw in Ft. Lauderdale and Miami rejected my case, Michel says. They told me they couldn t operate without blood, and that s an operation I wasn t willing to have. With the help of his children and members of his local congregation, Michel s case was brought to the attention of Herbert Dardik, MD, Chief of Vascular Surgery at Englewood Hospital. Dr. Dardik has been performing vascular surgery since the 1960s, and he thought his team at The Institute might have a solution for Michel. OFFERING HOPE In about 90 percent of abdominal aortic aneurysms, doctors use a minimally invasive approach to correct the problem, Dr. Dardik says. We thread a tiny tube up through the groin and to the site of the damage. There is minimal bleeding and no need for a transfusion. But Michel s case was different. His kidneys weren t getting the blood they needed to survive from the affected area. Michel needed additional reconstruction to make sure blood flow to his kidneys wouldn t be interrupted when we corrected the aneurysm. Most doctors perform a large, open-incision surgery when this happens. For Michel, that wasn t an option. 2 CHOICES TIC_W15_H25818_05.indd 2

3 FINDING THE RIGHT BLOODLESS SOLUTION For families concerned about the use of blood transfusions in medical procedures, it s important to find the right solution. The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center is a comprehensive program designed to deliver the latest medical advances while honoring patients wishes to avoid blood transfusions. It s important to do the research and find the right solution for your unique medical situation, like my patient Michel Alexandre did, says Herbert Dardik, MD, Chief of Vascular Surgery at Englewood Hospital. Talk to others about their experiences. At The Institute, I work with a team of professionals from multiple medical disciplines. Together, we re prepared to respond in the best interest of our patients, whatever comes our way. DR. DARDIK TOLD ME, YES! WHEN EVERYONE ELSE TOLD ME, NO! HE GAVE ME HOPE. I WOULD RECOMMEND ENGLEWOOD HOSPITAL TO ANYONE WHO IS SICK AND NEEDS CARE. Michel Alexandre Dr. Dardik and Michel Alexandre Instead of recommending a risky open procedure that could cause Michel to lose a substantial amount of blood, Dr. Dardik suggested a new minimally invasive approach. Dr. Dardik s willingness to help was amazing, Michel says. Instead of rejecting my case, he gave me hope. He took the time to talk with me and explain the situation. He told me I was very sick and that it would be a challenge, but that he was up to the challenge. SOMETHING EXTRAORDINARY On May 27, 2014, Dr. Dardik and his colleagues at The Institute performed an innovative minimally invasive procedure to correct Michel s aneurysm. Before surgery, they boosted Michel s blood levels with iron to help ensure that any blood he lost would have little or no effect on his well-being. Using an image-guided technique called intraoperative fluoroscopy, Dr. Dardik and his colleague, interventional radiologist Phillip Bahramipour, MD, carefully threaded minuscule tubes through Michel s blood vessels starting in the groin and also from a small opening in one of his arm arteries. First, we placed small stents in the arteries that feed his kidneys, Dr. Dardik says. Then we placed the main stent, repairing the portion of the aorta that carries blood to the lower half of the body. When we finished, he had three new avenues for blood flow the main graft supplying the lower half of the body and the two smaller grafts supplying the kidneys. This isn t a standard approach. In fact, it s something rather extraordinary. And we re able to do it here because we ve created a team of experts who can work together to find the best, minimally invasive approaches for patients like Michel. The procedure took six hours to complete. Afterward, Michel was moved to the intensive care unit to recover just as a precaution. Within a week, he was out of the hospital. I stayed in New Jersey with my family for about a month and a half, Michel says. I had a few follow-ups and everything looked fine. Now, I m back home in Florida, and life is good. Michel is now under the care of his physicians in Ft. Lauderdale. He returned to Englewood Hospital for a checkup with Dr. Dardik in October. Michel is recovering beautifully, Dr. Dardik says. This is a great example of a family who did the research and found the right solution for them even when other hospitals told them no. The Institute provides bloodless care to patients from around the world. To learn more about The Institute, visit For a referral to a blood management physician, call CHOICES 3 TIC_W15_H25818_05.indd 3

4 Building Relationships, Changing Lives Susan Clifford, MD For Susan Clifford, MD, nephrologist at The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center, the ability to develop relationships with her patients made pursuing medicine an easy choice. Medicine is a social career, Dr. Clifford says. I ve always had a mind for science and math, and practicing medicine allows me to interact with others while pursuing those interests. When you practice nephrology [the specialty of medicine that focuses on kidney diseases], you see patients frequently and become very close as a result. You re not just part of their lives you re part of their families. A member of The Institute s team for the past 10 years, Dr. Clifford specializes in management of chronic and acute kidney diseases and treatment of high blood pressure. Because frequent use of blood transfusions to manage end-stage kidney disease can limit an individual s ability to receive a kidney transplant, Dr. Clifford is particularly passionate about the delivery and advancement of bloodless medicine. Outside the hospital, Dr. Clifford enjoys dancing she s taken ballet classes for as long as she can remember traveling and baking. Cupcakes and creatively designed cakes are among her culinary areas of interest. For a referral to a blood management physician at The Institute, call A High-impact Life Lyall Gorenstein, MD Former marathoner and competitive skier Lyall Gorenstein, MD, FACS, may have taken his athletic pursuits down a notch or two, but the difference he makes in patients lives is anything but low-impact. Dr. Gorenstein a thoracic surgeon at The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center competed in downhill skiing and waterskiing while growing up in Canada. He later took up marathon running and considers the New York City Marathon his favorite race. Dr. Gorenstein still skis with his family, but golfing and cycling have replaced waterskiing and distance running in his athletic repertoire. Sports help him stay mentally and physically fit for performing trailblazing thoracic surgery. We re developing a thoracic surgery program that features a team of surgeons, pulmonologists, and oncologists offering university-level care with a focus on minimally invasive procedures, says Dr. Gorenstein, who joined Englewood Hospital in January At Englewood Hospital, patients can have the most complex, technically challenging procedures in a community hospital setting. To Dr. Gorenstein, practicing bloodless medicine is a no-brainer. Bloodless surgery is good for all patients it just makes sense, he says. It is a privilege to work with multiple specialists across many disciplines to provide high-quality care that respects individuals wishes for bloodless medicine. For a referral to a blood management physician at The Institute, call CHOICES TIC_W15_H25818_05.indd 4

5 A Trip to Do Dale and Amber Davis The Impossible After being denied a bloodless hysterectomy in her hometown, Amber Davis, 59, traveled nearly 2,000 miles to have her surgery her way at The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center. In March 2014, Amber and her husband Dale learned Amber had uterine papillary serous carcinoma, an aggressive form of cancer in the lining of the uterus, and that Nimesh Nagarsheth, MD she needed a total hysterectomy. Amber quickly realized that it would be difficult to find a physician who respected her beliefs as one of Jehovah s Witnesses. We were shocked when my oncologist in Dallas told me I couldn t have the hysterectomy without a transfusion, Amber says. My husband and I both volunteer full-time at the Assembly Hall of Jehovah s Witnesses in San Antonio, Texas, and after talking with the Branch Office, we were sent to The Bloodless Institute at Englewood Hospital. THE PERFECT FIT Amber came to see me on April 28, 2014, and within 24 hours, she had her testing done, including chest X-rays, computed tomography scans, and blood work, says Nimesh Nagarsheth, MD, Director of Gynecologic Oncology and Director of Robotic Surgery at Englewood Hospital and Medical Center. On May 9, she had a robotic hysterectomy, removal of tubes and ovaries, and an extended cancer staging procedure, but she was still able to go home the same day of her surgery. Her postoperative blood count was actually higher than her pre-operative blood count. The recovery after the surgery really was incredible, Amber says. I had the surgery on Friday, and I was moving around and visiting with friends the entire weekend. I took two pain pills total after my procedure. According to Dr. Nagarsheth, Amber went from having an extremely aggressive cancer that no one was willing to treat according to her wishes, to getting some of the best care available. Bloodless patients deserve the same treatment opportunities as anyone else, he says. We have the background and experience to take care of anyone who needs gynecologic surgery, but especially those who do not take blood transfusions. The fact that The Institute respects the wishes of bloodless patients shows that the physicians here are all about the patients, Amber says. As Jehovah s Witnesses, we ve made a choice based on our conscience, and we love that the medical staff here supports us. To learn more about The Institute, visit WHAT REALLY IMPRESSED ME IS BEFORE WE MET WITH THE SURGEON, MY HUSBAND AND I WERE SHOWN A VIDEO THAT EXPLAINED HOW THE BLOODLESS TECHNIQUES WORKED AND ALLOWED US TO MAKE AN INFORMED DECISION. IT WAS AN AMAZING EXPERIENCE IN EVERY WAY. Amber Davis CHOICES 5 TIC_W15_H25818_05.indd 5

6 WHAT YOU SHOULD KNOW ABOUT Blood Thinners By Jeffrey S. Matican, MD, FACC, cardiologist at The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center Not all blood thinners are created equally. Knowing the differences is essential for the safe management of patients who don t accept blood transfusions. Blood thinners can be a major concern for all patients, but especially for those in the bloodless community. The major side effect of blood thinners is, of course, bleeding. Treatment of bleeding may require interventions that traditionally involve blood transfusion, but that is not an option for bloodless patients. When working with your physician, what do you need to know in order to make the right decision for you? WHAT ARE THE OPTIONS? There are three types of blood-thinning medications: thrombolytics, anti-platelet agents, and anticoagulants. Thrombolytics are used in a hospital setting to dissolve already formed clots. Anti-platelet agents, the most common of which is aspirin, are used to prevent the formation of small clots. Anticoagulants are used predominantly Jeffrey S. Matican, MD to treat and prevent large clots, which are most common in patients with atrial fibrillation, deep vein thrombosis, and mechanical heart valves. Until very recently, the only oral anticoagulant available was warfarin (Coumadin ). Warfarin has its disadvantages. It requires continual monitoring and frequent dosage adjustment. Many drug and food interactions can also decrease or increase its blood-thinning capacity and lead to either clotting or bleeding. The most devastating disadvantage of warfarin is the risk of intracranial hemorrhage the bleeding stroke. The most common agent that reverses the blood-thinning effect of warfarin is vitamin K. Unfortunately, it takes as long as 24 hours to achieve its desired effect, which may be too long in a bleeding patient. However, other newer medications can reverse the effects of warfarin much more quickly. Such risks led to the development of novel oral anticoagulants (NOACs). There are now three commercially available warfarin substitutes: dabigatran (Pradaxa ), rivaroxaban (Xarelto ), and apixaban (Eliquis ). Many patients prefer these drugs because they do not have any food interactions, have much fewer drug interactions than warfarin, and do not require frequent blood test monitoring. In addition, all three available warfarin substitutes cause less bleeding strokes compared to warfarin. It is important to remember, however, that while antidotes are available to reverse the effects of warfarin, no reversal agents are currently available for blood thinners such as dabigatran, rivaroxaban, and apixaban an important bit of knowledge for a patient who does not accept blood. Without an antidote to reverse the effects of these drugs, it may be difficult, if not impossible, to compensate for any blood loss. However, promising reports indicate an antidote for both dabigatran and apixaban may become available within the next year. The bottom line is that not all blood thinners are the same, nor are they potentially safe for patients who do not accept transfusions. While bleeding is rare in patients on any type of blood thinner, if it does occur, bloodless patients are best treated in a medical center experienced in the theory and practice of transfusion-free medicine. By knowing how different blood thinners function, how complications might arise with each, and how to reverse or treat their unintended effects, physicians at The Institute can provide the best possible care for the bloodless patient. To learn more about The Institute, visit For a referral to a blood management physician, call CHOICES TIC_W15_H25818_05.indd 6

7 Medical Director s Corner THE INSTITUTE RECEIVES PRESTIGIOUS HONOR During the Society for the Advancement of Patient Blood Management s (SABM) 2014 Annual Meeting in Houston, Texas, Englewood Hospital and Medical Center was recognized for its leadership in the field of patient blood management. SABM was founded in 2001 to research the positive impact of blood management programs while serving as an educational resource for professionals and the public. Today, SABM partners with physicians, hospitals, and health systems around the world to advance comprehensive patient blood management practices. Left to right: Richard Melseth, Director of Project Development for SABM; Aryeh Shander, MD, Immediate Past President, SABM, and Executive Medical Director of The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center; Sherri Ozawa, RN, Executive Director of SABM and Director of The Institute; and Art Bracey, MD, President, SABM Redefining WHAT S POSSIBLE By Aryeh Shander, MD, Executive Medical Director at The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center In this issue of Choices, we ve featured patients who were told that their disease could not be cared for at other hospitals, only to find out they could be and successfully were treated here at The Institute. These are not extraordinary occurrences. Most physicians at our Institute would recount stories of patients who were transferred here Aryeh Shander, MD from other hospitals when they were told that nothing could be done for them because they did not accept transfusions. There are usually one of two reasons why these patients are denied care elsewhere. For some, they are told it would be impossible to treat them that their particular condition was too complex or required sophisticated techniques that weren t available there. In other cases, the hospital was simply unwilling to adapt their care to meet patients religious convictions or medical preferences. Our mission has always been and always will be to carefully and clearly establish methods of treatment that honor our patients convictions and their medical goals and not to deny care simply because these convictions clash with old dictums in medicine. We have intentionally built our culture around this mission, and that culture in turn has attracted and produced innovative physicians who are willing to think progressively in order to improve care for their patients. Our ability to continually redefine what is possible is simply the result of our commitment to always putting our patients first. To learn more about The Institute, visit For a referral to a blood management physician, call CHOICES 7 TIC_W15_H25818_05.indd 7

8 350 Engle Street Englewood, NJ Nonprofit Org. U.S. Postage PAID Madison, WI Permit No. 428 Choices is a publication of the Marketing and Communications Department of Englewood Hospital. This publication in no way seeks to serve as a substitute for professional medical care. Consult your physician before undertaking any form of medical treatment or adopting any exercise program or dietary guidelines. Early Detection: THE KEY TO BREAST CANCER TREATMENT Francis Forte, MD By Francis Forte, MD, Senior Medical Director at The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center At The Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital and Medical Center, an emphasis on screening and early detection is revolutionizing breast cancer care. When diagnosed in its early stages, breast cancer is highly treatable. All too often, however, diagnosis is delayed, which poses particular challenges for women who do not wish to receive blood transfusions during cancer treatment. Optimizing bloodless surgical care involves treating underlying anemia a condition characterized by low levels of red blood cells prior to surgery. For women in need of a mastectomy or partial mastectomy, addressing anemia may delay surgical treatment, underscoring the need for an early diagnosis. Use of chemotherapy for more advanced cancer also presents unique difficulties, especially if the chemotherapy is delivered before surgery. Treatment of cancer that has spread to other areas of the body requires use of drugs that may lower red blood count and compromise white blood cells and platelets. When breast cancer is diagnosed in early stages, we don t have to use therapies that will compromise the blood. WHEN TO SCREEN The American Cancer Society recommends all women receive annual mammograms starting at age 40. According to Dr. Forte, women with a family history of breast cancer should begin mammogram screenings at 35. Englewood Hospital specializes in the early detection of breast cancer and offers the latest screening technologies and genetic testing for BRCA gene mutations. Identifying these genetic mutations, which can run in families and increase a woman s likelihood of developing breast and ovarian cancer, helps doctors pinpoint women in need of rigorous screening and/or preventive therapies. Women with a personal or family history of breast cancer diagnosed before age 50, women of Ashkenazi Jewish descent, and women with ovarian cancer are all candidates for genetic testing. To learn more about The Institute, visit For a referral to a blood management physician, call TIC_W15_H25818_05.indd 8

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